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�IMY 1 E1 I/t ✓ LOT NO.
NO. SIA EF.I'
j® PT N FOR PLUMBING PERMIT
C Y OF CUPLRTINO
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z o ��A Sanitary No. �p
30 I)at 11`3 Permit No
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CI Fee $
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0 Application Qferr��f the City of Cupertino for a permit to install plumbing
°o 1- pipes and/or fixtures IistedtildI� erse side hereof, and agrees to install said prices
> i- and/or fixtures in accordance w�rtl'i'Hfe provisions of the Plumbing Code of the City of
aw Cupertino, and all other applicable thereto.
W Use of Premises wC\
00
> 0 ( ht�r/< GTS
0 3 Owner Address
zBy Address 7Y csy /&d/"
O CONTRACTOR, AGENT
3 ` Phone �/qr�— � 3ya
N
W Z
0 f State License/ z ` 7 Approved
a o (/
U . I PLUMBING INSPECTOR
-FIXTURES
UNITS FEES UNITS FEES
Water Heatc Size
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks / Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks - To Main Drain
Comb. Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee --
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
Jprinkler Valves Water Sys. Fee 4
Permit Fee - °'--!—
TOTAL TOTAL FEE e '
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final